Healthcare Provider Details

I. General information

NPI: 1700389376
Provider Name (Legal Business Name): LEAH C O'DELL LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N CHURCH ST
PALESTINE TX
75801-2381
US

IV. Provider business mailing address

638 AN CR 170
ELKHART TX
75839
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-3602
  • Fax: 903-731-9573
Mailing address:
  • Phone: 903-724-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2214398
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: